Question

A nurse is administering a cleansing enema for a client who has constipation. Which of the following actions should the nurse take?

A. Keep the container of solution at a level that is comfortable for the client.
B. Hold the container of solution 3 0cm (12 inch) above the anus.
C. Hold the container of solution level with the upper hip.
D. Slowly lower the container of solution 61 cm (24 inch) below the anus.

Answer 1

The nurse should hold the enema solution container 30 cm (12 inches) above the anus to properly administer a cleansing enema to a client with constipation.

Step-by-step explanation:

When administering a cleansing enema for a client with constipation, the nurse should hold the container of solution at the correct height to ensure the proper flow of the enema solution into the colon. The correct height is not level with the client's comfort or the hip, nor is it to be lowered below the anus. Instead, the nurse should hold the container 30 cm (12 inches) above the anus. This height allows gravity to facilitate the flow of the enema solution into the sigmoid colon, which is shaped like the letter 'S' and leads into the rectum, eventually helping to clear out fecal matter and relieve constipation.

The correct action that the nurse should take is B. Hold the container of solution 30 cm (12 inches) above the anus.